The American Accreditation HealthCare Commission/URAC (URAC) has an accreditation program specifically for case management services. From the answer choices below, select the response that correctly identifies the type(s) of case management services addressed by URAC's standards and the type

(s)

of organizations to which these standards may be applied.

A.

Type(s) of Services-on-site services only Type(s) of Organization-health plans only

B.

Type(s) of Services-on-site services only Type(s) of Organization-any organization that performs case management functions

C.

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-health plans only

D.

Type(s) of Services-both telephonic and on-site services Type(s) of Organization-any organization that performs case management functions

In order to achieve changes in outcomes, health plans make changes to existing structures and processes. The introduction of preauthorization as an attempt to control overuse of services is an example of a reactive change. Reactive changes are typically

A. both planned and controlled

B. planned, but they are rarely controlled

C. controlled, but they are rarely planned

D. neither planned nor controlled

Comparing the quality of managed Medicare programs with the quality of FFS Medicare programs is often difficult. Unlike FFS Medicare, managed Medicare programs

A. can measure and report quality only at the provider level

B. use a single system to deliver services to all plan members

C. provide an organizational focus for accountability

D. can use the same performance measures for all products and plans

The case management program director at the Nova Health Plan calculated the program's ratio of medical expense savings to case management administrative costs for the previous quarter based on the following cost information:

Administrative costs for case management ..........$40,000 Actual medical care expenses for patients under case management ..........$680,000 Projected medical care expenses for the same patients without case management ..........$900,000 This information indicates that, for the previous quarter, Nova's ratio of medical expense savings to case

management administrative costs was

A. 0.71/1

B. 0.80/1

C. 5.50/1

D. 1.25/1

Outcomes management is a tool that health plans use to maximize all the results associated with healthcare processes. The following statement(s) can correctly be made about outcomes management:

1.The goal of outcomes management is to identify and implement treatments that are cost- effective and deliver the greatest value

2.Outcomes management introduces performance as a critical factor in the assessment and improvement of outcomes

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

The following statements are about health plans' use of electronic data interchange (EDI). Three of the statements are true and one is false. Select the answer choice containing the FALSE ALSE statement.

A. One advantage of EDI over manual data management systems is improved data integrity.

B. EDI may use the Internet as the communication link between the participating parties.

C. EDI involves back-and-forth exchanges of information concerning individual transactions.

D. The data format for EDI is agreed upon by the sending and receiving parties.

Performance variance can be classified as either common cause variance or special cause variance. The following statement(s) can correctly be made about special cause variance:

1.Inadequate staffing levels, employee errors, and equipment malfunctions are examples of special cause variance 2.Special cause variance is typically more difficult to detect and correct than is common cause variance

A. Both 1 and 2

B. 1 only

C. 2 only

D. Neither 1 nor 2

Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Ray's condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although Harbrace's medical policy for migraine headache does not include coverage of Upzil, Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.

In this situation, the prescribing of Upzil for Ms. Ray's headaches is an example of

A. a cosmetic service

B. an investigational service

C. an off-label use

D. a quality-of-life service

For this question, if answer choices (A) through (C) are all correct, select answer choice (D). Otherwise, select the one correct answer choice.

In most commercial health plans, the case management process is directed by a case manager whose responsibilities typically include

A. focusing on a disabled member's vocational rehabilitation and training

B. approving all care decisions for patients under case management

C. reducing the fragmentation of care that often results when individuals obtain services from several different providers

D. all of the above

The following statement(s) can correctly be made about the characteristics of peer review: 1.Peer review is applicable to either single episodes of care or to entire programs of care 2.Most peer review is conducted concurrently 3.Under the Health Care Quality Improvement Program (HCQIP), peer review is required for services

furnished to Medicare and Medicaid recipients enrolled in health plans

A. All of the above

B. 1 and 2 only

C. 1 and 3 only

D. 2 and 3 only